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HomeMy WebLinkAbout0881 ~ MARYIl~iiD STA7f DEPARL`~1ENi OF HEALTH ; Division of STATIAKAL RESEARCH AND RECORDS, 301 W. PRESTON STREET, BAITIM,ORE, A1ARYlAND 21201 rZS3SS~ MEDICAL EXAMINER'S CERTIFiCA~E OF DEATt~ 1. MA(E OF DEAiN 1. USUAI ~ES40ENCE ~~~lf! dt(!OSld MtllA. A r111 :ul,pA ~tYCtM! FIt~61! OGl~Kl~OI~~ ~ ' = c ; " a (p~ry o. SIAtt • p (OUKiY I : c-; l.:-~ l~u~atrlA.tiO /~~n c~iO - ~ ~ .S~ ' CL ~ / j S. (Itt OR i01MN (N outsde corpaWe k~nds, c lEliGiH Oi STA~ IM i? t Clir OR 16LYN (It outs~de torp~xWe Lmds, wnle RURl1l and g~+t newetl ~o~wej i ' i e~ r t? ~ = ~ ~ G BURN IE .f~ ,(~c / .c= ~ W j a. NA1AE Of HOSPIiAI OR piSI1iUTI0N (N nw n Aospea~ gne streN oddreu) d. SiREEi ADDtESS e IS RiS~DiPdE H ~ Qti A FARM7 ~ ~ ~ ~ ~ 4 Q c~ - ~.,o.s.l~f?. !~I ~C vw+ ~a .C . /Z F STi ~v - ~vSw~E rts ? r;o.~' . r,`` 3. NAME Oi Frst Middie los~ . DATE Month Doy rta _ i i ~ D~(EA~SE Onntl ~ oTT/~ ~l DEAiIi Z 7"' 19 = S. SOC ~(OCOt CR,RA(E l. YA~2:fD lCEYER MARR~D ~ t U~iF OF 3~RTn 9 AGE y:~ ye..-n !c ~~:c= ~ r;a2 :F ~•.:;R 1<~zS. ~ ~ ' ' /V~ W rriOOVrED ~ O~ORCED ~ i L ~ - ~ 4 0 ( ~TSra~ Wa-.rs ~}-.yz ?+c.a Mn. i ~ c! ~ i Ipo UiUA( 0((IiiAliON (G~ve ino d wat da~e IOb- klNb OF BUSttiESi OR 11. 6iRTHPIA(E (Stoh a tortyn country) It AiIIF~ Of wr+AT ' ~ ' ~ dvn •,ast ~ sg de. trcn A rctre~ IkC' iRT (0 'S T21' ~/Y _ ~q ~ S ~/trq /b C r ld F~Iw:i S ARVi Y3'-F2 vA.Ji.\ Kkv~ . , h ~f ~~a ~y n /~rto wrr~ = c~~ IS. WASOECEASEDEYfRWU.S ARMEDFORCES? li. SOfUH SE(URITY Ii0 U. WFOB1tANT ' Ik~ress . r. O~(Yes, ro or unkro+~n) M yes gm wa a dotes d semce 7 o . ~ . . -9566 ' ~'.sr~~w~a.~. /o.~ S~ e a~ tt uus~. OF.o~?tN (~ua oa. ~ws. va r~. to. (o~, (e~, wd I~ 1 IhTERVAt @(CrrEFN ; _ ~ i riu~t c of~ia ~ us~o er: ~T. IUC~E COUNTY f• a: Af60 DfAiH " ~ :,_r-__L i~ ~ uunE ~O~ ~-a'~B.w..~ ROCE~ ~QiSRAS ~ ~ _ ~_-"~c 6UE i0 ( ,y~'-'""_ RECOR~YE*.If1E0 . - . ~ ~ ~ ~ ~ :-a.~.;~~d; r.~, `1 'i ' stolay iM uo~~. ~9_:C-o~s~' TO - ~ 6 ~ 1 i 3 ~ 1 1nt. ,;,.7'~'~ c~~..f ~ ~ j~ ?~R'f./, 0, i~Fl(Alp RIBUTINCr TO DfATN BU1 NOi RELAifD TO THE i[RMWAI DISEASf (OND11i0N GIYEN IM PART 1(0) 19' p~(RFO2M~ED ~ . j ~ ~ ~ ~ `~i_ - > r ' Tfs ? Ii0 1^~ ~ . . . y I i ~ Ea ~~oo,~ ExYU~l,lll y ~ IOb. OES(YIBE NO'W IplURll 0((URREO. (Enta aown ol ~ry w Pat 1 a Pon II ol ~ean i{ ) : ~ ~ , ' ~ '~o~DFADI. 'a%'4 ti 1 ' t, a . 20d UWR~ OC(URRED 20~. PIACE Oi IN11iRr (Ffom~. iam. Z01 (Gh a towni lCou^ryl) (S~mt) ~r~ i o w~~ Wwl~ NW IMhde lac?ory. ~tra~, oftKe Wdg., ek.) : . C:. ~~,.,-E'~ N m,Nak ? olwak ? ~ A; 21: 1 tArtif~ took chorge ol the remains uribed obove. held an Autopsy tnspection , Inquiry . and in my opinion - deoth re om: Noturo) causes Accident Suicide Homicide Undetermined manner ? ~ (WEf AIfDI(Al EXAMINER ? F ~ ~~u ~p IISSISTANi MEW(AL El(MAINER ? 2t. OATE SIWlED ~ r; . E7(AMIIER'f OEPUiY AbfDKAI EXAIMINER ~ r '-P~ ' = ~ ~ ~ ~ a,~~ ~ = • ? ti ~ d ~ . ~s~,S~~. « z- z ~c - c 6 . 3 H t3s. ~RW,~ fA{11ilON. 136. TF i IfAMf Of (EAAEiE OR RE. r I3d. l0( 110N ~Gryr w Town) ((ounry~ (Store) ; -r 1J p11 {S~qe;t~) ~y ~~~(0 6 o~.eol~v a~ ,~r?e~i' l3 ~ $ t` ~S ' OA ~~C~18 ~ EWS~ IV S- ~ REGSiiGRS?~ ??Qt . /L!~'.s ' K ~ ~ , ' ~ _ - - - - - ~ k ? . ~ _.~s~-~'-;~" y .-~'s~"`;ar~;'~?nw,.__._~... : ~°'_'~y . .z... _ '